Every finding on record at Medi-Plex Health Care Professionals, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/06/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A standard survey for Medicare recertification for the home health provider was completed on 12/06/2023. The provider had 78 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on the provider’s policy, clinical record review, and interview, the home health provider failed to ensure clinicians perform a review of all medications the patient was currently using in two of six records (Records/Patients #1 and #2). This deficient practice has the potential to affect the medication review and reconciliation for all of the provider’s patients. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated February 2021, showed, in part: - At the time of admission, the admitting [clinician] will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency: * Any concerns or discrepancies will be reconciled by a registered nurse (RN) with the patient’s physician/practitioner; - Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; - The agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by agency staff and staff acting on behalf of the agency; and - In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to [the] RN for review, who contacts physician/practitioner if indicated. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of hemochromatosis (genetic disorder that can cause severe liver disease and other health problem), and secondary diagnoses including, but not limited to, gastroesophageal reflux (a condition in which stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hyperlipidemia (elevated levels of lipids (fats) in the blood), and long-term use of antiplatelet agents. The patient resided in their own home with the assistance of family/friends. Comparison of the medication list sent to the provider at the time of referral on 10/13/2023 to the plan of care dated 11/14/2023 showed, in part the following discrepancies: - The referral medication profile listed multiple medications that were not included on the provider’s medication profile including acetaminophen (a non-narcotic pain reliever), clotrimazole (a cream used to treat skin conditions), diazepam (a medication used to treat anxiety and depression), lansoprazole (used to treat gastric reflux), latanoprost (a medication used to treat glaucoma), metronidazole (a medication used to treat skin conditions), and polyethylene glycol (a medication used to treat constipation); and - Multiple medications appeared on the provider’s medication profile and were not listed on the referral medication list including clopidogrel (to prevent blood clots), pantoprazole (used to treat gastric reflux), rosuvastatin (to reduce lipids in the blood), and vitamin B12. Review of the start of care visit dated 11/14/2023 showed the clinician documented that a medication reconciliation was performed and there were no issues found during the medication review. The visit documentation failed to contain documentation that the physician was notified of the discrepancies between the referral medication list and the provider’s medication profile. During an interview on 12/06/2023 at 11:42 AM, the administrator stated that they were unable to locate documentation that the clinician had notified the physician of discrepancies identified during the start of care medication reconciliation. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 10/24/2023 for wound care following an exploratory laparotomy (an incision into the abdominal cavity), abdominal mesh removal, and small bowel resection (removal) on 10/16/2023. The patient resided in their own home with the assistance of family and friends. Secondary diagnoses are hypertension, atrial fibrillation (fluttering of the upper portion of the heart), osteoarthritis, anxiety, benign prostatic hypertrophy. Comparison of the medication list sent to the provider at the time of referral on 10/19/2023 to the plan of care dated 10/24/2023 showed, in part the following discrepancies: - The referral medication profile listed medications that were not included on the provider’s medication profile including aspirin (used to prevent blood clots), ketoconazole (used to treat skin conditions), lisinopril 40 milligrams (mg) take one half tablet daily (for high blood pressure), multivitamin, and omega-3 oils; and - Multiple medications appeared on the provider’s medication profile and were not listed on the referral medication list including lisinopril 40mg take one tablet daily, potassium chloride, and sildenafil (for erectile dysfunction). Review of the start of care visit dated 10/24/2023 showed the clinician documented that a medication reconciliation was performed and there were no issues found during the medication review. The visit documentation failed to contain documentation that the physician was notified of the discrepancies between the referral medication list and the provider’s medication profile. During an interview on 12/06/2023 at 4:00 PM, the administrator stated that they were unable to locate documentation that the clinician had notified the physician of discrepancies identified during the start of care medication reconciliation.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on the provider’s policy, observation, and interview, the home health provider failed to ensure their clinicians followed standard precautions, to prevent the transmission of infections and communicable diseases in two of three home visit observations (Records/Patients #2 and #4). This deficient practice has the potential to affect the standard precautions utilized for all of the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Bag Technique Procedure,” showed that the bag technique procedure included, in part: - Observe principles of universal precautions and body substance isolation at all times. The inside of the nursing bag shall be regarded and maintained as a clean area; - Open the nursing bag and remove items that are needed to wash the hands. Handwashing supplies should be kept in the side pocket or at the top of the bag. Close the bag. Open and close the nursing bag as few times as possible; and - Open the nursing bag again and remove items necessary for the visit. Apply personal protective equipment. Keep the bag close during the visit. Provide patient care. If additional equipment or supplies are needed form the bag during the home visit, the handwashing procedure must be repeated. Clean any items from the bag, which have become soiled. Place then on a clean a paper towel. Repeat handwashing procedure and return equipment to bag at the end of the visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 10/24/2023 for wound care following an exploratory laparotomy (an incision into the abdominal cavity), abdominal mesh removal, and small bowel resection (removal) on 10/16/2023. The patient resided in their own home with the assistance of family and friends. Secondary diagnoses are hypertension, atrial fibrillation, osteoarthritis, anxiety, benign prostatic hypertrophy. During a home visit observation on 12/05/2023 at 3:45 PM, the clinician entered the patient’s home wearing a surgical mask and gloves on both hands. The clinician entered his/her clinical bag wearing the gloves donned prior to entering the home, and without performing hand hygiene. He/she then removed the blood pressure cuff and pulse oximeter from the bag, monitored the patient using the equipment, and returned the equipment to the clinical bag without cleansing the equipment or removing the soiled gloves and performing hand hygiene. During an interview on 12/06/2023 at 4:00 PM, the administrator stated that the bag techniques utilized during this visit failed to follow the agency policy. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of non-pressure chronic ulcer on right foot, and secondary diagnosis of lymphedema. The patient resided in their own home. During a home visit observation on 12/05/2023 at 1:36PM, the clinician performed wound care with the following breaks in infection control. The clinician: - Removed the old dressing from the patient’s leg and placed the dressing in the trash. He/she failed to perform hand hygiene or remove his/her gloves before reaching into a package of clean gauze; - Cleansed the patient’s wound with spray wound cleaner, wiped the wound with clean gauze, failed to perform hand hygiene or change gloves, and reached back into the package of clean gauze to get more (this was repeated three times); and - Assessed the patient’s vital signs, failed to wash his/her hands, reached into his/her bag, retrieved a box of alcohol preps (sat the prep box on the table without a drape), cleansed the equipment with an alcohol prep, and returned the equipment and contaminated box of alcohol preps back into the nursing bag. During an interview on 12/06/2023 at 11:42 AM, the administrator stated that the bag techniques utilized during this visit failed to follow the agency policy.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on the provider’s policy, clinical record review, and interview, the home health provider failed to ensure the clinicians provided the services that were ordered by the physician as indicated in the plan of care in one of six records reviewed (Record/Patient #4). This deficient practice has the potential to affect the provision of care as ordered for all of the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Missed Visit Policy,” showed: - The agency will ensure accurate documentation of all missed visits and when to report the missed visit to the physician; - To provide written documentation to the physician, when applicable and in the patient’s medical record of when visits are missed within the scheduled visit week (Sunday-Saturday) for all patients; - Procedure: * The clinician will document when scheduled visits are missed due to various reasons and record the reason accurately; * The clinician will make other attempts to visit the patient within the service week to adhere to the patient’s frequency according to the plan of care; * The clinician will report missed visits to the physician when visits are missed excessively; and * MD/Physician and/or wound care clinic appointment(s) may or may not apply to meeting the patient’s frequency for the service week. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/14/2023 with a primary diagnosis of non-pressure chronic ulcer on right foot, and secondary diagnosis of lymphedema. The patient resided in their own home. Review of the plan of care dated 11/14/2023 showed the nurse was to visit two times per week for the provision of wound care. The nurse was to cleanse the wound with normal saline, apply gentamycin cream, Algicel Ag (an absorbent dressing impregnated with silver), Hydrofera Blue (a dressing used to reduce bacterial growth), cover with dry dressing, and secure with tape. Apply with two-layer Coflex (a compression dressing). The week of 11/26 the patient did not have any nursing visits for provision of wound care. The clinical record failed to contain documentation that the physician was notified of the missed visits and that the patient did not receive wound care for that week. During an interview on 12/06/2023 at 11:42 AM, the administrator stated that they would expect the clinician to notify the physician of missed visits and that wound care was not provided as ordered.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on policy review, employee file review, and interview, the agency failed to ensure staff were provided emergency preparedness training annually for one (Employee #2) of three employee files reviewed. This deficient practice has the potential to affect emergency preparedness practices for all agency staff. Findings included: Review of the agency's policy titled, "Emergency Operations Plan," dated 2015, showed: - Policy: The agency administrator, director of clinical services and staff implement emergency operations plan, as appropriate; - Purpose: To describe the agency's approach to responding to internal and external emergencies that would suddenly and significantly affect the need for services, plans for patients, or the ability to provide such services; - Ongoing staff education and training will occur annually as part of an exercise or in response to an actual emergency. EMPLOYEE #2 (E2): - Registered Nurse (RN); - Date of hire: 08/31/2010; - No documentation of emergency preparedness training annually for E2. During an interview on 04/01/2021 at 10:00 AM, the chief executive officer (CEO) stated he/she thought E2 had other training during 2020 and COVID 19 had made it difficult for staff to get or be in-serviced on issues other than COVID 19.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on agency policy, review of the agency's emergency preparedness information, and interview, the agency failed to conduct exercises to test the emergency plan annually and analyze the agency's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the agency's emergency plan as needed. This deficient practice has the potential to affect the emergency preparedness for all patients served by the agency. Findings included: Review of the agency policy revised in 2015 and titled, "Emergency Operations Plan," showed that the emergency plan: - Will be tested and evaluated annually at each site; and - Leaders, managers, and staff will evaluate each emergency response exercise and all responses to actual emergencies, and the evaluation would: * Include identification of deficiencies and opportunities for improvement; * The plan would be modified based on the evaluation of deficiencies and opportunities for improvement; and * Future planned exercises will reflect modifications and any interim measures described in the plan. Review of the agency's Emergency Preparedness information failed to show documentation of: - An emergency event or drill for the years of 2018 and 2019; and - An evaluation of the emergency drill performed in 2017. During an interview on 03/31/21 at 03:15 PM the administration stated that the agency did not have documentation of: - The emergency drills performed in 2018 and 2019, and - The evaluation of the emergency drill performed in 2017.

An extended survey for Medicare certification for Medi-Plex Healthcare Professionals, LLC was completed on 04/01/2021. The agency had 165 current patients. Two condition level deficiencies were identified during this survey at: - §484.60 Condition of Participation: Care planning, Coordination of Services, and Quality of Care; and - §484.75 Condition of Paticipation: Skilled Professional Services. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and one deficiency was identified related to the Focused Infection Control Survey. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey completed on 04/01/21. Two standard level deficiencies were identified.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include the patient has the right to be advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid or any other Federally funded or Federal aid program known to the agency; be advised of the charges for services that may not be covered by Medicare, Medicaid or any other Federally funded or Federal aid program known to the agency; be advised of the charges the individual may have to pay before care is initiated; and be advised of any changes in the information when they occur, as soon as possible, in advance of the next home health visit. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: Review of the agency's policy titled "Patient's Bill of Rights/Responsibilities and Transfer/Discharge Criteria dated January, 2020 showed: - Patients have the right to be advised of the extent to which payment for services may be expected from Medicare, Medicaid or any other Federally funded or Federal aid program known to the agency; - Be advised of the charges for services that may not be covered by Medicare, Medicaid or any other Federally funded or Federal aid program known to the agency; - Be advised of the charges the individual may have to pay before care is initiated; - Be advised of any changes in the information provided with respect to payment and changes, if they occur. The patient and representative(if any) are advised of these changes as soon as possible, in advance of the next home visit; and - Receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care or in advance of the agency reducing or terminating on-going care. Agency will comply with the Federal requirements. The administrator provided an admission packet for review on 03/30/3031. The agency's notice of rights and other information, given to the patient during the initial visit, did not contain the patient right to be advised orally and in writing of the extent to which payment for home health agency services may be expected from Medicare, Medicaid, or any other Federally funded or Federal aid program known to the agency. During an interview on 03/31/2021 at 2:00 PM, the administrator stated orally and in writing needed to be added to the statement in the policy and the patient rights given to the patients upon admission.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to ensure staff reviewed of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions in two (Records/Patients #1 and #3) of three home visit records reviewed. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: Review of agency policy revised January 2020 and titled, "Initial Assessments/Comprehensive Assessments," showed, in part, the following: - Each patient's comprehensive assessment includes a review of all medications the patient is currently taking as well as times of medication administration and routes; Review of agency policy revised March 2018 and titled, "Medication Reconciliation," showed, in part, the following: - The agency will reconcile patient's medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy; - At time of admission, the admitting clinician will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency; - Medications ordered while the patient is receiving care will be compared to the medication list/profile. the medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated. RECORD/PATIENT #1: Patient admitted on 07/07/2020 with primary diagnosis of insulin dependent diabetes (a disease in which blood sugar levels in the blood are elevated over a long period of time), and secondary diagnoses of anemia, and chronic kidney disease. Client recertified on 03/04/21 for continued care of diabetes with chronic kidney disease, long term use of insulin and management of lower extremity wounds. Medications reviewed during a home visit observation on 03/31/21 at 12:20 PM with the patient and registered nurse. A comparison of the agency medication profile (AMP), the home medication profile (HMP), and patient reported medications was completed with the following findings: - AMP/HMP showed the patient was taking Lasix (a pill used to remove excess fluid from the body) daily, the patient reported (TPR) and the registered nurse stated that this medication has been on hold for "awhile"; - HMP showed that the patient was to take tacrolimus (a medication used to prevent transplant organ rejection) 1 milligram (mg) tablet, 5 tablets two times per day, the AMP showed, and TPR, that the patient was to take 4 tablets two times per day; - The HMP showed that the patient was to take acarbose (a medication used to lower blood sugar) 100 mg daily, the AMP failed to list the medication; - AMP/HMP showed the patient was to take aspirin 81 mg daily, the prescription medication bottle in the home showed client to take enteric coated aspirin (an aspirin tablet with a coating designed to dissolve in the intestine instead of the stomach) 81 mg daily; - AMP/HMP showed the patient was to take duplicate medications Myfortic (a medication used to prevent organ rejection after transplant) 360 mg two times daily and mycophenolate mofetil (the generic form of Myfortic) 250 mg every 12 hours, TPR that he/she takes 360 mg two times per day; - AMP/HMP showed the patient was to take duplicate medications ropinirole (a medication used to treat restless legs and leg cramping) 1 mg tablet at noon and bedtime and Requip (the name brand for ropinirole) 0.25 mg, two tablets daily in the morning, TPR taking the medication three times per day; and - AMP/HMP showed the patient was to receive a Procrit (a medication used to stimulate the development of red blood cells to treat anemia) subcutaneous (under the skin) injection weekly. TPR that the nurse administers the injection weekly. During an interview on 03/31/21 at 12:20 PM, the registered nurse stated that he/she administers the injection intramuscularly. Home visit observation findings reviewed with the administration and clinical manager on 03/31/21 at 3:45 PM with no further evidence provided before survey exit. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted on 03/20/2021 with a primary diagnosis of weakness, and secondary diagnoses of abnormalities of gait and mobility, essential hypertension (high blood pressure), visual loss of the left eye, dysphagia (difficulty swallowing), obstructive sleep apnea (stop breathing when sleeping because of airway obstruction), vitamin D deficiency, epilepsy (seizure disorder), major depression, history of falls, and a history of prostate cancer. During the home visit observation on 03/31/2021 at 1:20 PM the surveyor compared the home medication profile (HMP), agency medication profile (AMP), and interview with the spouse. The patient's spouse reported that the nurse practitioner (NP) from the Veterans Administration made a home visit on 03/24/2021 and made changes to the patient's medications. The nurse had not made a visit since that date. The physical therapist performed an evaluation visit on 03/25/21. Findings included: - AMP/HMP showed that the client was to take Cozaar (a medication used to treat high blood pressure) 100 milligram (mg), take one tablet daily and the spouse reported (TSR) the NP instructed them to take Cozaar 50 mg daily beginning 03/24/21; - AMP/HMP showed that the client was to take hydralazine 100 mg tablet three times per day and TSR the NP instructed them to stop the medication on 03/24/21; - AMP/HMP showed that the client was to take metoprolol succinate daily and TSR the NP instructed them to stop the medication on 03/24/21; - AMP/HMP showed that the client was to take polyethylene glycol (a medication used to treat constipation) daily, TSR that the patient only takes the medication as needed for constipation; and AMP showed that the sertraline (a medication used to treat depression) was discontinued on 03/20/21 and TSR that the patient is taking the medication daily. The findings of the home visit observation were reviewed with the administrator and clinical manager on 03/31/21 at 3:45 PM with no additional information/documentation provided before survey exit.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to meet the requirements for the Condition of Participation: Care Planning, coordination of services, and quality of care, when the agency failed to: - Provide an individualized plan of care that included all required elements (G574); - Provide a visit schedule, including frequency of visits to the patient (G614); - Provide a copy of written instructions outlining any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services (G618); and - Provide the name and contact information for the clinical manager to the patient (G622). The cumulative effect of these deficient practices has the potential to affect the care of all patients served by the agency.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interviews, the agency failed to ensure that each patients' written individualized care plan included all the required elements in, but not limited to, three (Records/Patients #1, #2, and #5) of five full records reviewed. This deficient practice has the potential to impact the care provided to all agency patients. Finding included: Review of the agency policy revised March 2019 and titled, "Plan of Care," showed: - The individualized plan of care must include the following: * All pertinent diagnoses; * The frequency and duration of visits to be made; * Nutritional requirements; * All medications and treatments; * A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors; and * Patient-specific interventions and education; measurable outcomes and goals identified by the home health agency and the patient; and - Orders for services to be furnished 'as needed' or 'PRN' must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit. RECORD/PATIENT #5: Patient admitted to home health services on 12/23/2020 with primary diagnosis of osteomyelitis (a bone infection) of the jaw and intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC). Review of the referral information provided to the agency on 12/22/20 showed that: - The patient was seen on 12/17/2020 for treatment of osteomyelitis of the jaw; - A culture was obtained of the drainage from the patient's right jaw on 12/18/2020; - The culture resulted as a methacillin sensitive staphylococcus aureas (a staph infection); - The patient received IV antibiotics during the hospital stay; and - A PICC was placed on 12/20/2020. Review of the wound assessment from the hospital dated 12/19/2020 showed the patient had a wound on the right jaw with exposed hardware that was scabbed and left open to air. Review of the hospital discharge summary dated 12/22/2020 showed: - Physical exam at discharge showed "exposed bone right flap" and drainage decreased from the right jaw; - Requesting home health care and infusion therapy; - Home health services were requested for wound/ostomy care; - The patient was to receive infusion services for IV antibiotics; and - Requested start of care date was 12/23/2020. Review of the orders from the infusion company showed that the agency was to: - Maintain PICC with normal saline (NS) 10 milliliter (ml) and heparin (a blood thinner) 10 units/ml per established protocol; - Cefazolin 2 grams (GM) (a broad spectrum antibiotic used to treat infections) in NS 100 ml. Infuse intravenously over 60 minutes every 12 hours by Elastomeric device (a device used for infusing IV medications); - Obtain weekly comprehensive metabolic profile (CMP) and complete blood count (CBC); - Nursing visits weekly for patient assessment, teaching, IV catheter care, and labwork; and - 8 as needed visits for additional teaching, PICC care, labs, or other symptom management. The plan of care dated 12/23/2020 showed: - The medication list contained the following: * Cefazolin 2 GM in 20 ml intravenous solution, twice a day intravenous. (The order failed to contain the name of the diluent and listed an incorrect volume to be infused. The order failed to identify the infusion frequency of every 12 hours as ordered from the infusion company); * Heparin flush 100 units/ml intravenous solution, give 5 ml per saline/antibiotic/saline/heparin (SASH) method intravenous. (The order listed an incorrect strength of heparin at 100 units/ml instead of 10 units/ml as listed on the prescriber orders from the infusion company); - The list of durable medical equipment and supplies failed to contain PICC insertion site care and infusion items; - The skilled nurse visit frequency failed to contain a reason for the PRN (as needed) visits; - The plan of care failed to contain orders for care of the PICC insertion site, weekly labwork, and assessment of the wound on the right jaw; and - The discharge plan included the phrase, "wound(s) are healed". The findings were reviewed with the administration and clinical manager on 03/31/21 at 4:10 PM, no additional information was provided before the end of the survey. RECORD/PATIENT #1: Patient admitted on 07/07/2020 with primary diagnosis of insulin dependent diabetes (a disease in which blood sugar levels in the blood are elevated over a long period of time), and secondary diagnoses of anemia, and chronic kidney disease. Client recertified on 03/04/21 for continued care of diabetes with chronic kidney disease, long term use of insulin and management of lower extremity wounds. Review of the plan of care dated 03/04/21 failed to contain: - Orders for use of the Dexcom 6 device (a device that continuously measures the amount of sugar in the blood) or a listing of the device in the durable medical supplies; - A diagnosis for the wounds on the bilateral lower extremeties (the diagnosis for which the nurse makes the most frequent visits); - Orders for the management of diabetes; or - Orders for nutritional requirements. During a home visit observation on 03/31/21 at 11:30 AM, the nurse asked the patient about his/her blood sugar readings. The client checked his/her phone and reported that the blood sugar reading was "High". The surveyor asked the patient about the glucose monitoring device being used, and the nurse stated that the patient uses a Dexcom 6 device to monitor his/her blood sugars and he/she changes the probes weekly. The findings were reviewed with the administration and clinical manager on 03/31/21 at 4:00 PM, no additional information was provided before the end of the survey. RECORD/PATIENT #2: Review of the plan of care (POC) dated 03/17/2021 through 05/15/2021 showed: - Diagnoses included: Chronic kidney disease, abnormalities of gait and mobility, Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer (PU) to the right buttock, deep tissue injury to the right heel, colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to excrete fecal material), history of falls, bed confinement, and long term use of anticoagulants (blood thinning medication); - Skilled nurse (SN) to perform complete physical assessment each visit with emphasis on wound care, assess other co-morbidities, notify the physician immediately of any potential problems that impede completion of patient recovery and desired goals, perform wound care: clean buttocks open area with antibacterial soap and water, pat dry, calmoseptine (a moisture barrier that prevents irritation) cream and leave open to air; - Home health aide (HHA) to provide assistance with personal care and activities of daily living; - The initial POC failed to include documentation for frequency of SN visits. - The initial POC and the HHA care plan failed to include documentation for frequency of HHA visits. Review of the SN start of care visit dated 03/17/2021 showed: - SN instructed the care giver to clean the Stage II wound to the right buttock with normal saline. The SN cleaned the Stage II wound with normal saline. - No order was found in the record for use of normal saline to cleanse the wound. During an interview on 03/31/2021 at 2:00 PM, the chief executive officer (CEO) state: - He/she spoke with the nurse who performed the wound care and the nurse wrote an order for the normal saline on 03/31/2021.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, review of the current patient rights information, home visit observation, and interview, the agency failed to ensure the staff provided a written visit schedule to patients that included what discipline was visiting, and the frequency of visits in one (Patient/Record #2) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Patient's Bill of Rights/Responsibilities and Transfer/Discharge Criteria dated January, 2020 showed: - Patients have the right to participate in, be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to the frequency of visits. RECORD/PATIENT #2: Review of the admission packet during a home visit observation on 03/31/2021 at 10:45 AM showed: - The agency notice of patient rights and other information given to the patient during the initial visit contained; the right to be informed of the types (disciplines) which will be provided and the frequency of the visits that are proposed; and - A blank copy of the calendar to be used to record discipline visits for the patient/caregiver. During an interview on 03/31/2021 at 11:00 AM the patient's caregiver stated: - The agency staff did not record on the calendar when visits would be performed; - Staff called him/her the day before to let him/her know when they would be making a visit; - He/she would like for the visits to be recorded so that he/she could plan her schedule around the visits. During an interview on 03/31/2021 at 2:00 PM, the administrator stated that staff should record their visits on the calendar included in the admission information packet.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to assure the patient/caregiver was notified of any treatments to be administered by the agency personnel in one (Record/Patient #1) of three applicable records reviewed. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: Review of agency policy revised January 2020 and titled, "Patient's Bill of Rights," showed that the patient has the right to be informed of treatments to be administered by agency staff and other pertinent instructions related to care. RECORD/PATIENT #1: Patient admitted on 07/07/2020 with primary diagnosis of insulin dependent diabetes (a disease in which blood sugar levels in the blood are elevated over a long period of time), and secondary diagnoses of anemia, and chronic kidney disease. Client recertified on 03/04/21 for continued care of diabetes with chronic kidney disease, long term use of insulin and management of lower extremity wounds. During the provision of wound care the nurse applied an ointment to the areas of intact skin on the patient's legs. The mother, who provides wound care in the nurse's absence stated, "I didn't know to do that". The nurse did not follow up with the mother on this statement. Review of the agency folder in the patient's home failed to contain current wound care instructions for the mother to reference in the absence of the nurse. During an interview with the nurse on 03/31/21 at 12:20 PM the nurse acknowledged that the patient instructions in the home did not contain the current treatment orders.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on policy review, review of the current patient rights information, home visit observation, and interview, the agency failed to ensure each patient received written information related to the name and contact information of the agency's clinical manager in the admission packet during the initial assessment in one (Record/Patient #2) of three applicable home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient's Bill of Rights/Responsibilities and Transfer/Discharge Criteria," dated January, 2020 showed: - The patient has the right to be informed of the name of the clinical manager and contact information. RECORD/PATIENT #2: During a home visit observation on 03/31/2021 at 10:45 AM, the admission packet of information that should include the clinical manager's name and contact number, failed to include that information. During an interview on 03/31/2021 at 2:00 PM, the administrator stated that the clinical manager's name and contact information should be in the home information packet.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee file review, and interview, the agency failed to ensure staff were provided infection control training annually for one (Employee #2) of three employee files reviewed. This deficient practice has the potential to affect infection control practices of all agency staff. Findings included: Review of the agency's undated policy titled, "Infection Control Annual Training," showed: - Policy: The agency developed and implanted infection control practices that conform to OSHA (Occupational Safety and Health Administration whose mission is to "assure safe and healthy working conditions for working men and women by setting and enforcing standards and by providing training) regulations, CDC (Centers for Disease Control and Prevention), accreditation requirements, federal, state, and local regulations, and currently accepted standards of practice. The administrator is assigned responsibility for the management of infection prevention and control activities; - Purpose: To prevent or decrease the exposure of patients and employees to diseases and infections and to establish and maintain a surveillance program of identifying, reporting, and analyzing infections; - Provide annual training to staff regarding infection control to include exposure to fluids, tissues or other potentially infectious material or other blood borne pathogens; - Annual training will address appropriate use of PPE (personal protective equipment; gloves, masks, gowns, etc.); and - Annual training will include review of the Infection Control Plan in place. EMPLOYEE #2 (E2): Review of E2's employee file showed: - Registered Nurse (RN); - Date of hire: 08/31/2010; - No record of annual infection control training for 2020. During an interview on 04/01/2021 at 10:00 AM, the chief executive officer (CEO) stated he/she thought E2 had other training during 2020 and COVID 19 had made it difficult for staff to get or be in-serviced on issues other than COVID 19.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on policy review, record review, observation, and interview the agency failed to meet the requirements for the Condition of Participation: Skilled Professional Services, when the agency failed to: - Ensure skilled professional staff provided the services that were ordered by the physician as indicated in the plan of care (G710); - Ensure the skilled professionals assumed responsibility for preparing clinical notes (G716); and - Ensure all staff participated in agency in-service trainings (G722). The cumulative effect of this deficient practices has the potential to affect all of the agency's patients.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interviews, the agency failed to ensure professional staff provided services ordered by the physician as indicated in the plan of care for two (Records/Patients #1 and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of agency policy dated November 2016 and titled, "Wound Care Policy," showed: - At each visit the patient's skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri-wound skin condition; and - At least every week, the wound assessment and documentation will include measurement of length, width, depth, and undermining/tunneling if present. Review of the agency's undated policy titled, "Rehabilitation Services Time Frame," showed: - Policy: The agency will ensure accurate documentation and timeliness of all rehabilitation ordered services by the physician; - Purpose: To provide documentation of when initiation of rehabilitation services will start with the patient; - The clinician will document when scheduled rehabilitation evaluation and plan of care within seven days of the patient's start date; - The rehabilitation clinician will initiate rehab services within seven days of the start of care date for all ordered services from the physician; and - The rehabilitation clinician will record all missed visit attempts in the patient record. RECORD/PATIENT #1: Patient admitted on 07/07/2020 with primary diagnosis of insulin dependent diabetes (a disease in which blood sugar levels in the blood are elevated over a long period of time), and secondary diagnoses of anemia, and chronic kidney disease. Client recertified on 03/04/21 for continued care of diabetes with chronic kidney disease, long term use of insulin and management of lower extremity wounds. Review of the plan of care (POC) dated 03/04/21 showed: - The primary diagnosis for the patient was diabetes; - The patient was to receive Procrit (a medication used to treat anemia) subcutaneously (just under the skin) weekly; and - The nurse was to assess integumentary status, identify any signs and symptoms of impaired skin integrity, report significant changes to physician, and perform wound care to blistered, open wounds on both legs. Review of nursing visit documentation for 03/04/21 showed that the nurse administered the Procrit injection intramuscularly (into the muscle). Review of nursing visit for the weeks of 03/07/21 and 03/14/21 failed to show documentation of administration of the weekly Procrit injection. During an interview on 03/31/21 at 12:20 PM, the registered nurse stated that he/she administered the injection intramuscularly. The nursing visit documentation for 03/04/21, 03/09/21, 03/11/21, 03/16/21, 03/19/21, and 03/23/21 failed to contain a complete assessment of the wounds on the bilateral lower extremeties, including a description of the wound beds, drainage, healing, and wound measurements. RECORD/PATIENT #4: Review of the clinical record showed: - A communication note dated 12/30/2020 showed; received referral to evaluate the patient for OT services; awaiting return call from patient but will continue to reach patient; - A communication note dated 01/04/2021 (five days after the referral was received) showed OT attempted another call to the patient, but no answer and no return call received; and - OT evaluated the patient and developed the OT POC on 01/09/2021 (10 days after the order was received). The findings were reviewed with the administrator and clinical manager on 03/31/21 at 3:45 PM with no further evidence provided before survey exit.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and interview, the agency failed to ensure that skilled professional staff prepared complete clinical documentation in four (Records/Patients #2, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect the documentation of care for all patients served by the agency. Findings included: Review of agency undated policy titled, "Missed Visit Policy," showed: - The clinician will document when scheduled visits are missed due to various reasons and record the reason accurately; - The clinician will make other attempts to visit the patient within the service week to adhere to the patient's frequency; and - The clinician will report missed visits to the physician when visits are missed excessively. Review of agency undated policy titled, "Central Venous Catheters - Care of Peripherally Inserted Central Catheters," showed the nurse would: - Document date of tubing or adapter change on care plan or other appropriate document; and - Document dressing change and condition of insertion site on appropriate record. Review of agency policy revised October 2017 and titled, "Timely Submission of Patient Documentation," showed: - Physicians' orders must be submitted to the agency within three business days after receipt; - Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three business days. All patient visit reports from contract personnel must be submitted within three business days from the date of the visit; and - Upon discharge from services, the patient discharge summary must be submitted within five business days. Review of the agency's undated policy titled, "Rehabilitation Services Time Frame," showed: - Policy: The agency will ensure accurate documentation and timeliness of all rehabilitation ordered services by the physician; - Purpose: To provide documentation of when initiation of rehabilitation services will start with the patient; - The clinician will document when scheduled rehabilitation evaluation and plan of care within seven days of the patient's start date; - The rehabilitation clinician will initiate rehab services within seven days of the start of care date for all ordered services from the physician; and - The rehabilitation clinician will record all missed visit attempts in the patient record. RECORD/PATIENT #5: Patient admitted to home health services on 12/23/2020 with primary diagnosis of osteomyelitis (a bone infection) of the jaw and intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC). Review of nursing visit documentation showed the registered nurse (RN) visits dated 12/29/2020, 01/05/21, 01/12/21, 01/19/21, and 01/26/21 failed to contain documentation that the dressing to the PICC insertion site, change of IV tubing, and labwork had been performed. Clinical record review findings presented to the administrator and clinical manager on 03/31/21 at 3:45 PM with no further evidence provided before survey exit. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted on 03/20/2021 with a primary diagnosis of weakness, and secondary diagnoses of abnormalities of gait and mobility, essential hypertension (high blood pressure), visual loss of the left eye, dysphagia (difficulty swallowing), obstructive sleep apnea (stopping breathing when sleeping because of airway obstruction), vitamin D deficiency, epilepsy (seizure disorder), major depression, history of falls, and a history of prostate cancer. Review of the clinical record showed the physical therapist performed the physical therapy evaluation on 03/25/2021. The state surveyor requested a printed copy of the physical therapy evaluation on 03/31/21. During an interview on 03/31/21 at 4:00 PM the administrator stated that the physical therapist had not submitted the completed documentation until 03/31/2021. RECORD/PATIENT#2: Review of the clinical record showed: - The occupational therapy (OT) plan of care (POC) dated 03/19/2021 included a frequency of visits 1w1 (one time per week for one week) and 2w4 and the OT evaluation was performed on 03/19/2021; - No documentation for visits the week of 03/21/2021 were found in the record; - The administrator spoke with the OT and visits were made on 03/23/2021 and 03/25/2021; the OT had not documented the visits; - The 03/23/2021 missed visit note was documented and placed in the record on 03/31/2021, eight days after the missed visit; and the 03/25/2021 missed visit note was documented and placed in the record on 03/31/2021, six days after the missed visit; - The initial POC did not show a frequency for the home health aide (HHA); - The HHA care plan did not show the HHA frequency of visits; - A HHA correction order dated 04/01/2021 (the last day of the survey) showed HHA frequency 2w8 starting week of 03/21/2021; and - The record showed one HHA visit made the week of 03/21/2021. During an interview on 03/31/2021 at 2:00 PM, the chief executive officer (CEO) stated: - The administrator or case manager usually notify the physician of missed visits and staff should document why visits were missed. The findings were reviewed with the administrator and clinical manager on 03/31/21 at 3:45 PM with no further evidence provided before survey exit.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on employee file review, and interview, the agency failed to ensure staff were provided with agency in-service training in one (Employee #2) of three employee files reviewed. This deficient practice has the potential to affect all agency staff. Findings included: No policy obtained related to other trainings for staff. EMPLOYEE #2 (E2): Review of E2's employee file showed: - Registered Nurse (RN); - Date of hire: 08/31/2010; - No record of in-service trainings in 2020. During an interview on 04/01/2021 at 10:00 AM, the chief executive officer (CEO) stated he/she thought E2 had other training during 2020 and COVID 19 had made it difficult for staff to get or be in-serviced on issues other than COVID 19.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and interview, the agency failed to ensure that the aide provided services that were included in the plan of care in one (Record/Patient #3) of two applicable records. This deficient practice has the potential to affect the aide services for all patients served by the agency. Findings included: Review of the agency policy revised March 2018 and titled, "Home Health Aide (HHA) Documentation," showed that: - The HHA will document services rendered to the patient on the appropriate Home Health Aide charting form as directed in the Aide care plan/assignment sheet; and - The HHA will be responsible for reporting any changes in the patient's condition and/or other pertinent observations to the supervising registered nurse/therapist. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted on 03/20/2021 with a primary diagnosis of weakness, and secondary diagnoses of abnormalities of gait and mobility, essential hypertension (high blood pressure), visual loss of the left eye, dysphagia (difficulty swallowing), obstructive sleep apnea (stopping breathing when sleeping because of airway obstruction), vitamin D deficiency, epilepsy (seizure disorder), major depression, history of falls, and a history of prostate cancer. Review of the HHA assignment sheet showed assignments including, but not limited to, performance of hair care and combing of the hair, incontinence care, and turning and positioning of the patient. Review of the HHA visit documentation, dated 03/29/21, failed to contain documentation of the performance of hair care and combing of the hair, incontinence care, and turning and positioning of the patient, or registered nursing notification of failure to perform the assigned tasks.